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Michigan Trauma Board – October 2013 Michigan Trauma Board – October 2013

Michigan Trauma Board – October 2013 - PowerPoint Presentation

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Michigan Trauma Board – October 2013 - PPT Presentation

Michigan Trauma Board October 2013 An Introduction to ICD10CMPCS Objectives Whats changing what isnt ICD10 When Why Change ICD10 Around the World Australia 19981999 Brazil 1998 ID: 772158

character icd external body icd character body external code codes part fracture encounter activity coding pcs initial injury system

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Michigan Trauma Board – October 2013 An Introduction to ICD-10-CM/PCS

Objectives

What’s changing, what isn’t? ICD-10, When?

Why Change?

ICD-10 Around the World Australia 1998-1999 Brazil 1998 Canada 2001 China 2002 France 2005 Germany 1998 Korea 2008 Netherlands 1994 Russia 1999 South Africa 1996 Sweden 1997 Thailand 2007 United States 2014 United Kingdom 1995 U.A.E (Dubai) 2012

When will this occur?

What are ICD-10-CM and ICD-10-PCS? ICD = I nternational C lassification of D iseases 10 = 10 th Revision CM = C linical M odification PCS = P rocedure C lassification S ystem ICD-10-CM Diagnosis code set ICD-10-PCS Procedure code set

Comparing ICD-9 to ICD-10

The following is taken from the World Health Organization Committee for the Coordination of Statistical Activities Twenty-second Session 4-6 September 2013 discussing ICD 11: In conclusion: (a) WHO Secretariat could produce an ICD 2015 ready including Mortality and Morbidity Linearizations , Reference Guide and Index with the appropriate resolution to go to the World Health Assembly. This timeframe , however, is extremely tight for paying due diligence to the work especially in terms of: appropriate consultations with expert groups; and sufficient time for field testing in multiple countries and settings, and carrying out the resulting edits (b) If the timeline is advanced to 2016, there will be more time to have ICD 2016 version with more translations and incorporations of some field tests results.(c) If the timeline is advanced to 2017, ICD 2017 will be ready with most Field Test results incorporated and maintenance scheme tested. What about ICD-11?

“Assuming that ICD-11 becomes available on schedule in 2016, the earliest the United States could move to ICD-11 would be 2025. That's 12 years from now. Can we really afford to wait that long? If you don't have the clinical analytics to survive in the changing health care environment we're facing, you may not survive until 2025 to find out .” Leon- Chisen , Nelly. "If We Procrastinate Long Enough, Will ICD-11 Be Ready?." H&HN . n.d. n. page. Web. 1 Oct. 2013. <http://www.hhnmag.com/hhnmag/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/03MAR2013/0313HHN_ahavoices&domain=HHNMAG>. What about ICD-11?

Benefits of ICD-10-CM

Benefits of ICD-10-CM ICD-10-CM incorporates much greater clinical detail and specificity than ICD-9-CM. Terminology and disease classification have been updated to be consistent with current clinical practice. The modern classification system will provide much better data needed for: Measuring the quality, safety, and efficacy of care Reducing the need for attachments to explain the patient’s condition Designing payment systems and processing claims for reimbursement;

Benefits of ICD-10-CM Conducting research, epidemiological studies, and clinical trials; Setting health policy; Operational and strategic planning; Designing health care delivery systems; Monitoring resource utilization; Improving clinical, financial, and administrative performance; Preventing and detecting health care fraud and abuse; and Tracking public health and risks. Note: Some non-specific codes still exist for use when the medical record documentation does not support a more specific code.

ICD-9-CM/ICD-10-CM: Similarities and differences

Structural Similarities and Differences between ICD-9-CM and ICD-10-CM Diagnoses

ICD-9-CM Structure - Format X X X X X 3-5 Characters Category Subclassification Subcategories

ICD-9-CM Structure –Format 3 - 5 Characters - Examples 042 Human immunodeficiency virus disease 496 Chronic airway obstruction, NEC 414 . 00 Coronary atherosclerosis of unspecified vessel, native or graft V 55.3 Attention to artificial openings, colostomy 274.03 Chronic gouty arthropathy with tophus

ICD-10-CM Structure –Format X X X X X X Category Etiology, Anatomic Site, Severity 7 th Character X 3-7 Characters

ICD-10-CM Structure –Format 3 - 7 Characters - Examples B20 Human immunodeficiency virus disease J44.9 Chronic obstructive pulmonary disease, unspecified I12.510 Atherosclerotic heart disease of native coronary artery without angina pectoris Z43.3 Encounter for attention to colostomy M1A.0111 Idiopathic chronic gout, right shoulder, with tophus

ICD-10-CM: Similarities to ICD-9-CM Divided into Alphabetic Index and Tabular List Structure and format are the same Index is alphabetical list of terms and their corresponding codes Alphabetic Index lists main terms in alphabetical order with indented subterms under main terms Index is divided into sections: Index to Diseases and Injuries Table of Neoplasms Table of Drugs and Chemicals External Cause of Injuries Index

ICD-10-CM: Similarities to ICD-9-CM Divided into Alphabetic Index and Tabular List Tabular List is a chronological list of codes divided into chapters based on body system or condition Tabular List is presented in code letter/number order Same hierarchical structure Codes are invalid if they are missing an applicable character Chapters in Tabular structured similarly to ICD-9-CM, with minor exceptions A few chapters have been restructured Sense organs (eye and ear) separated from Nervous System chapter and moved to their own chapters Codes are looked up the same way Look up diagnostic terms in Alphabetic Index Then verify code number in Tabular List

ICD-10-CM: Similarities to ICD-9-CM Many conventions have same meaning Abbreviations , punctuation, symbols, notes such as “code first” and “use additional code” Nonspecific codes (“unspecified” or “not otherwise specified”) are available to use when detailed documentation to support more specific code is not available

ICD-10-CM: Similarities to ICD-9-CM ICD-10-CM Official Guidelines for Coding and Reporting accompany and complement ICD-10-CM conventions and instructions Website for ICD-10-CM guidelines 2014 http:// www.cdc.gov/nchs/data/icd9/icd10cm_guidelines_2014.pdf Adherence to the official coding guidelines in all healthcare settings is required under the Health Insurance Portability and Accountability Act AHA is publishing information in Coding Clinic for ICD-10-CM/PCS Began Fourth Quarter 2012 Will become exclusively ICD-10-CM/PCS First Quarter 2014

ICD-10-CM: Differences from ICD-9-CM Codes are alphanumeric 1 st character is always alpha characters 2-7 are alphanumeric Codes can be up to 7 characters in length Codes are more specific Code titles are more complete (no need to refer back to a category, subcategory, or subclassification level to determine complete meaning of code ) Example: I12.0 Hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease

ICD-10-CM: Differences from ICD-9-CM Laterality (side of the body affected) has been added to relevant codes Expanded use of combination codes Certain conditions and associated common symptoms or manifestations Poisonings and associated external cause Injuries grouped by anatomical site rather than type of injury Codes reflect modern medicine and updated medical terminology

New Features

ICD-10-CM New Features Combination codes for conditions and common symptoms or manifestation Combination Codes –Examples I25.110 Atherosclerotic heart disease of native coronary artery with unstable angina pectoris K71.51 Toxic liver disease with chronic active hepatitis with ascites K50.012 Crohn’s disease of small intestine with intestinal obstruction N41.01 Acute prostatitis with hematuria

Code Comparison – Diagnosis Combination Codes Diagnosis: Diabetic retinopathy ICD-9-CM 250.50 Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled 362.01 Background diabetic retinopathy ICD-10-CM E11.319 Type 2 diabetes mellitus with unspecified diabetic retinopathy without macular edema

Breakdown of the ICD-10-CM Code E 1 1 3 1 9 Category- Type 2 Diabetes Mellitus Etiology, Anatomic Site, Severity- With unspecified diabetic retinopathy without macular edema 7 th Character- No 7 th Character 3-7 Characters

ICD-10-CM New Features Combination codes for poisonings and external causes T42.5x5A Adverse effect of mixed antiepileptics , initial encounter Added laterality S80.251A Superficial foreign body, right knee, initial encounter

ICD-10-CM New Features

ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, bWhen coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. Code T07, Unspecified multiple injuries should not be assigned in the inpatient setting unless information for a more specific code is not available. Traumatic injury codes (S00-T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds. The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first. ICD-10-CM New Features: Injuries

ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, b, 1 Superficial injuries such as abrasions or contusions are not coded when associated with more severe injuries of the same site. ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, b, 2 When a primary injury results in minor damage to peripheral nerves or blood vessels, the primary injury is sequenced first with additional code(s) for injuries to nerves and spinal cord (such as category S04), and/or injury to blood vessels (such as category S15). When the primary injury is to the blood vessels or nerves, that injury should be sequenced first. ICD-10-CM New Features: Injuries

ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, c The principles of multiple coding of injuries should be followed in coding fractures. A fracture not indicated as open or closed should be coded to closed. A fracture not indicated whether displaced or not displaced should be coded to displaced. ICD-10-CM New Features: Traumatic Fractures

ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, c, 1 Traumatic fractures are coded using the appropriate 7th character for initial encounter (A, B, C) while the patient is receiving active treatment for the fracture. Examples of active treatment are : surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. The appropriate 7th character for initial encounter should also be assigned for a patient who delayed seeking treatment for the fracture or nonunion. ICD-10-CM New Features: Traumatic Fractures

ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, d The ICD-10-CM makes a distinction between burns and corrosions. The burn codes are for thermal burns, except sunburns, that come from a heat source, such as a fire or hot appliance. The burn codes are also for burns resulting from electricity and radiation. Corrosions are burns due to chemicals. The guidelines are the same for burns and corrosions. ICD-10-CM New Features: Burns and Corrosions

ICD-10-CM Official Guidelines for Coding and Reporting 2014 - I, 19, d, 1 Sequence first the code that reflects the highest degree of burn when more than one burn is present. a. When the reason for the admission or encounter is for treatment of external multiple burns, sequence first the code that reflects the burn of the highest degree. b . When a patient has both internal and external burns, the circumstances of admission govern the selection of the principal diagnosis or first-listed diagnosis. c . When a patient is admitted for burn injuries and other related conditions such as smoke inhalation and/or respiratory failure, the circumstances of admission govern the selection of the principal or first-listed diagnosis. ICD-10-CM New Features: Burns and Corrosions

ICD-10-CM New Features: Placeholder “x” Character “x” is used as a 5th character placeholder in certain 6 character codes to allow for future expansion and to fill in other empty characters (e.g., character 5 and/or 6) when a code that is less than 6 characters in length requires a 7th character. When placeholder character applies, it must be used in order for the code to be considered valid Examples: T50.2 x 41A - Poisoning by carbonic-anhydrase inhibitors, benzothiadiazides and other diuretics, accidental (unintentional), initial encounter T16.2 xx A – Foreign body in left ear, initial encounter.

ICD-10-CM New Features: 7 th Character The 7 th character in ICD-10-CM is used in several chapters (e.g., the Obstetrics, Injury, Musculoskeletal, and External Cause chapters). It has a different meaning depending on the section where it is being used Injury and External Cause sections , the 7 th character classifies an initial encounter, subsequent encounter, or sequelae (late effect) Obstetrics the 7 th character is used to identify the fetus to which the code applies (used for single and multiple gestations) Must always be used in the 7 th character position If a code has an applicable 7 th character , the code must be reported with an appropriate 7 th character value in order to be valid

Injury and External Cause sections , the 7 th character classifies an initial encounter, subsequent encounter, or sequelae (late effect) Seventh character “A” initial encounter is used while the patient is receiving active treatment for the condition. Examples of active treatment are : surgical treatment, emergency department encounter, and evaluation and treatment by a new physician. ICD-10-CM New Features: 7 th Character “A”

Injury and External Cause sections , the 7 th character classifies an initial encounter, subsequent encounter, or sequelae (late effect) Seventh character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are : cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition. ICD-10-CM New Features: 7 th Character “D”

Injury and External Cause sections , the 7 th character classifies an initial encounter, subsequent encounter, or sequelae (late effect) Seventh character “S” sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using 7th character “S”, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code. The 7th character “S” identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code. ICD-10-CM New Features: 7 th Character “S”

ICD-10-CM New Features: Excludes Notes Two types of Excludes notes Excludes 1 – Indicates that the code excluded should never be used with the code where the note is located (do not report both codes). Or, restated- Means NOT CODED HERE Code being excluded is never used with code The two conditions cannot occur together Excludes1

ICD-10-CM New Features: Excludes Notes Excludes 1, Examples : Q03 – Congenital hydrocephalus Excludes 1: Acquired hydrocephalus ( G91.- ) M21 - Other acquired deformities of limbs Excludes1 : acquired absence of limb ( Z89.- ) congenital absence of limbs ( Q71-Q73 )

ICD-10-CM New Features: Excludes Notes Excludes 1, Examples : E10 - Type 1 Diabetes mellitus Excludes1: diabetes mellitus due to underlying condition ( E08.- ) drug or chemical induced diabetes mellitus ( E09.- ) gestational diabetes ( O24.4- ) hyperglycemia NOS ( R73.9 ) neonatal diabetes mellitus ( P70.2 ) type 2 diabetes mellitus (E11.-)

ICD-10-CM New Features: Excludes Notes Excludes 2 – Indicates that the condition excluded is not part of the condition represented by the code but a patient may have both conditions at the same time, in which case both codes may be assigned together (both codes can be reported to capture both conditions). Or, restated- Means NOT INCLUDED HERE Excluded condition is not part of the condition represented by the code Acceptable to use both codes together if patient has both conditions Excludes2

ICD-10-CM New Features: Excludes Notes Excludes 2, Examples: L27.2 – Dermatitis due to ingested food. Excludes 2: Dermatitis due to food in contact with skin (L23.6, L24.6, L25.4 ). L89 - Pressure ulcer Excludes2 : diabetic ulcers ( E08.621, E08.622, E09.621, E09.622 , E10.621 , E10.622, E11.621 , E11.622, E13.621, E13.622 ) non-pressure chronic ulcer of skin ( L97.- ) skin infections ( L00-L08 ) varicose ulcer (I83.0, I83.2)

External Cause of Morbidity What we formerly knew as “E-codes”

External cause of morbidity codes (categories V01-Y99) are reported with injury codes. External cause codes capture: Cause (how an injury occurred) Intent (accidental or intentional, e.g., suicide or assault) Person ’ s status (e.g., civilian, military, etc.) Place where the injury occurred Activity codes (category Y93) describe the activity of a person seeking care for injuries and health conditions: When the injury or other health condition resulted from the activity; or When the activity contributed to the injury or health condition. . External Cause of Morbidity

Codes for poisoning, adverse effect, and underdosing (categories T36-T50) and for toxic effects of substances chiefly nonmedicinal as to source (categories T51-T65) include information on the cause and intent. No external cause code from chapter 20 is needed for these codes. Examples: (Drug is Acetaminophen ) T39.1X1A Poisoning by 4-Aminophenol derivatives, accidental (unintentional), initial encounter T39.1X2A Poisoning by 4-Aminophenol derivatives, intentional self-harm , initial encounter T39.1X3A Poisoning by 4-Aminophenol derivatives, assault , initial encounter T39.1X4A Poisoning by 4-Aminophenol derivatives, undetermined, initial encounterT39.1X5A Adverse effect of 4-Aminophenol derivatives, initial encounterT39.1X6A Underdosing of 4-Aminophenol derivatives, initial encounterExternal Cause of Morbidity

Major categories of External cause codes include: V00-V99 Transport accidents W00-X58 Other external causes of accidental injury X71-X83 Intentional self-harm X92-Y09 Assault Y21-Y33 Event of undetermined intent Y35-Y38 Legal intervention, operations of war , military operations , and terrorism Y62-Y84 Complications of medical and surgical care Y90-Y99 Supplementary factors related to causes of morbidity classified elsewhere External Cause of Morbidity: Categories of External Cause Codes Mayhem!

External cause status codes (category Y99) describe work status of individual when the injury or health condition occurred during: Military activity. Non-military person at work. Student or volunteer involved in non-work activity. Includes activities done as a hobby, for leisure and recreation, and volunteer activity and activity of off-duty military personnel. Status External cause codes are not applicable to poisonings, adverse effects, misadventures, or late effects. Do not assign code Y99.9, Unspecified external cause status, if the status is not stated . External Cause of Morbidity: External Cause Status External cause status - military activity Y99.1

Category Y93 captures: Activity of the person at the time the injury or other health condition occurred. Activity codes are used only once, at the initial encounter for treatment. Only one code from Y93 should be recorded on a record. These codes are not applicable to poisonings, adverse effects, misadventures, or sequela . Coders should not assign code Y93.9, Activity, unspecified, if the activity is not stated. External Cause of Morbidity: Activity Codes Activity - mountain climbing Y93.31

Follow the sequencing hierarchy for External cause codes: External cause codes for child and adult abuse take precedence over all other External cause codes. External cause codes for terrorism events take priority over all other External cause codes except child and adult abuse. External cause codes for cataclysmic events take priority over all External cause codes except those for child and adult abuse and terrorism. External Cause Code Sequencing Hierarchy

Follow the sequencing hierarchy for External cause codes (cont.): Transport accidents take priority over all other External cause codes except those for cataclysmic events, child and adult abuse, and terrorism. Assign External cause codes for activity and external cause status following all causal (intent) External cause codes. First-listed External cause code should correspond to the cause of the most serious diagnosis due to an assault, accident, or self-harm, following the order of hierarchy above. A transport accident (V00-V99) is one in which the vehicle involved must be moving or running or in use for transport purposes at the time of the accident. A note at the beginning of the section defines the type of transportation vehicles included. External Cause Code Sequencing Hierarchy

Accidents caused by agricultural equipment are classified as transport accidents: If the equipment involved was a transport vehicle, when the accident occurred. Otherwise classified in categories W30 or W31, with a fourth character indicating the specific type of equipment. Agricultural Equipment

Separate External cause codes classify cause of injuries due to accident, self-harm, or assault. Code the intent as accidental when the intent is unknown or unspecified. All transport accident categories (V00-V99) assume accidental intent. The External cause code for undetermined intent should only be assigned if documentation specifies that the intent cannot be determined . External Cause of Injury Classified by Intent

Report category Y38, Terrorism, to describe injuries and illnesses due to terrorism. Codes Y38.0–Y38.9 follow the definition of terrorism established by the U.S. Federal Bureau of Investigation (FBI). Do not classify a death or an injury as terrorist-related unless the incident is designated as terrorism by the federal government. Multiple Y38 codes may be assigned if the injury is the result of more than one mechanism of terrorism (e.g., destruction of aircraft and firearm). Assign also a code from category Y92 to identify the place of occurrence . Terrorism

Assign category Y92, Place of occurrence of the external cause, for the place where an external event occurred. A place of occurrence code is used only once, at the initial encounter for treatment. No seventh character values are used with category Y92. Only one Y92 code is assigned on a record. Do not assign Y92.9 if place unknown. Codes from category Y92 refer only to the location, not the activity of the injured patient. Place of Occurrence

Codes for child and adult abuse facilitate the gathering of specific data. Adult abuse is underreported and underdiagnosed. Report child and adult abuse codes only if the physician documents the abuse. Coders should not interpret narrative descriptions as abuse without physician confirmation. Child and Adult Abuse

ICD-10-CM provides two categories for reporting adult and child abuse, neglect, or maltreatment: Confirmed (category T74) Suspected (category T76) The fourth character for categories T74 and T76 indicates the type of abuse: Neglect or abandonment Physical abuse Sexual abuse Emotional abuse Unspecified maltreatment The fifth character specifies whether child or adult abuse. The exception is code T74.4, Shaken infant syndrome: this code defaults to confirmed abuse . Child and Adult Abuse

ICD-10-CM does not specify the age limit for assignment of child abuse versus adult abuse codes. Depends on the age of majority, which varies among the states. If the patient has reached the age of majority per state guidelines, it would be appropriate to assign the adult abuse codes. If this information is not documented, the coder should query the provider. When abuse results in physical injuries or other conditions: Sequence the abuse code first (categories T74 or T76). Assign additional codes for associated injuries or mental health conditions documented by the physician. Assign an External cause code for perpetrator, if known (Y07.-). Confirmed adult and child abuse, neglect, and maltreatment is classified as assault. Assign code X92-Y09 to indicate the external cause of physical injuries resulting from the confirmed abuse. Child and Adult Abuse

Do not report External cause or perpetrator codes for suspected cases of abuse or neglect. If suspected abuse, neglect, or mistreatment is ruled out, code Z04.71 or Z04.72 is assigned. If suspected rape or sexual abuse is ruled out, code Z04.41 or Z04.42 is assigned. No code from category T76 is used for these encounters. Child and Adult Abuse

Let’s code! ICD-10-CM Practice

ICD-10-CM Coding Exercises 1. Closed traumatic fracture of shaft of left tibia and fibula, initial encounter. ICD-9-CM 823.22, Fracture of tibia and fibula, shaft, closed

ICD-10-CM Index Fracture , traumatic - fibula (shaft) ( styloid ) S82.40- Fracture, traumatic - tibia (shaft) S82.20- ICD-10-CM Tabular S82.2 Fracture of shaft of tibia S82.20 Unspecified fracture of shaft of tibiaFracture of tibia NOS S82.202 Unspecified fracture of shaft of left tibia S82.4 Fracture of shaft of fibula Excludes2 fracture of lateral malleolus alone (S82.6-) S82.40 Unspecified fracture of shaft of fibula S82.402 Unspecified fracture of shaft of left fibulaICD-10-CM Coding Exercises

S82 Fracture of lower leg, including ankle Note : A fracture not indicated as displaced or nondisplaced should be coded to displaced A fracture not indicated as open or closed should be coded to closed The open fracture designations are based on the Gustilo open fracture classification Includes: fracture of malleolus Excludes1: traumatic amputation of lower leg (S88.-) Excludes2: fracture of foot, except ankle (S92.-)periprosthetic fracture of prosthetic implant of knee (T84.042, T84.043) The appropriate 7th character is to be added to all codes from category S82 A - initial encounter for closed fracture B - initial encounter for open fracture type I or II initial encounter for open fracture NOS C - initial encounter for open fracture type IIIA, IIIB, or IIIC D - subsequent encounter for closed fracture with routine healing E - subsequent encounter for open fracture type I or II with routine healing F - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with routine healing G - subsequent encounter for closed fracture with delayed healing H - subsequent encounter for open fracture type I or II with delayed healing J - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with delayed healing K - subsequent encounter for closed fracture with nonunion M - subsequent encounter for open fracture type I or II with nonunion N - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with nonunion P - subsequent encounter for closed fracture with malunionQ - subsequent encounter for open fracture type I or II with malunionR - subsequent encounter for open fracture type IIIA, IIIB, or IIIC with malunionS - sequela ICD-10-CM Coding Exercises

1. Closed traumatic fracture of shaft of left tibia and fibula, initial encounter . S82.202A Unspecified fracture of shaft of left tibia, initial encounter S82.402A Unspecified fracture of shaft of left fibula , initial encounter ICD-10-CM Coding Exercises

ICD-10-CM Coding Exercises 2. Patient in car crash, brought to the hospital with a ruptured spleen and major contusion to the left kidney. (Diagnosis codes only.)

ICD-10-CM Index Rupture, ruptured - spleen (traumatic) S36.09 - - birth injury P15.1 - - congenital (birth injury) P15.1 - - due to P. vivax malaria B51.0 - - nontraumatic D73.5 - - spontaneous D73.5 ICD-10-CM Tabular The appropriate 7th character is to be added to each code from category S36 A - initial encounter D - subsequent encounter S - sequela S36.0 Injury of spleen S36.09 Other injury of spleen ICD-10-CM Coding Exercises

ICD-10-CM Index Contusion (skin surface intact) T14.8 - kidney S37.01- - - major (greater than 2 cm) S37.02- - - minor (less than 2 cm) S37.01- ICD-10-CM Tabular The appropriate 7th character is to be added to each code from category S37 A - initial encounter D - subsequent encounter S – sequelaS37.0 Injury of kidney Excludes2: acute kidney injury ( nontraumatic ) (N17.9) S37.02 Major contusion of kidney Contusion of kidney greater than 2 cm S37.021 Major contusion of right kidney S37.022 Major contusion of left kidneyS37.029 Major contusion of unspecified kidneyICD-10-CM Coding Exercises

ICD-10-CM Coding Exercises 2. Patient in car crash, brought to the hospital with a ruptured spleen and major contusion to the left kidney. S36.09xA Other injury of spleen, initial encounter S37.022A Major contusion of left kidney , initial encounter

ICD-10-CM Coding Exercises 3. Two-year-old patient ingested an unknown quantity of mother’s Enovid (birth control pills.)

ICD-10-CM TABLE of DRUGS and CHEMICALS ICD-10-CM Coding Exercises

ICD-10-CM Tabular The appropriate 7th character is to be added to each code from category T38 A - initial encounter D - subsequent encounter S – sequela T38 Poisoning by, adverse effect of and underdosing of hormones and their synthetic substitutes and antagonists , not elsewhere classified T38.4 Poisoning by, adverse effect of and underdosing of oral contraceptivesPoisoning by, adverse effect of and underdosing of multiple- and single-ingredient oral contraceptive preparations T38.4X Poisoning by, adverse effect of and underdosing of oral contraceptives T38.4X1 Poisoning by oral contraceptives, accidental (unintentional) Poisoning by oral contraceptives NOS T38.4X2 Poisoning by oral contraceptives, intentional self-harm T38.4X3 Poisoning by oral contraceptives, assault T38.4X4 Poisoning by oral contraceptives, undetermined T38.4X5 Adverse effect of oral contraceptivesICD-10-CM Coding Exercises

ICD-10-CM Coding Exercises 3. Two-year-old patient ingested an unknown quantity of mother’s Enovid (birth control pills.) T38.4X1A Poisoning by oral contraceptives, accidental (unintentional ), initial encounter

A woman was taking a walk along a rural road for exercise where she was struck from behind by a car. The patient suffered an open fracture of the right hip and a closed fracture of the ulna, left arm. The patient had an open reduction with internal fixation of the right hip. The left arm fracture was reduced and fitted with a cast. The patient was discharged in good condition. (Code the External Causes of Injuries codes only) ICD-10-CM Coding Exercises

ICD-10-CM External Cause of Injuries Index Accident (to) - transport - - pedestrian - - - on foot — see also Accident, pedestrian - - - - collision (with) - - - - - car V03.90 - - - - - - nontraffic V03.00- - - - - - traffic V03.10ICD-10-CM Tabular The appropriate 7th character is to be added to each code from category V03 A - initial encounter D - subsequent encounter S – sequela V03.1 Pedestrian injured in collision with car, pick-up truck or van in traffic accident V03.10 Pedestrian on foot injured in collision with car, pick-up truck or van in traffic accident Pedestrian NOS injured in collision with car, pick-up truck or van in traffic accidentV03.11 Pedestrian on roller-skates injured in collision with car, pick-up truck or van in traffic accidentICD-10-CM Coding Exercises: External Cause of Morbidity

ICD-10-CM External Cause of Injuries Index Place of occurrence - river Y92.828 - road Y92.488 - rodeo ring Y92.39 - rugby field Y92.328 ICD-10-CM Tabular Y92.4 Street , highway and other paved roadways as the place of occurrence of the external cause Excludes1 : private driveway of residence (Y92.014, Y92.024, Y92.043, Y92.093, Y92.113, Y92.123, Y92.154,Y92.194)Y92.48 Other paved roadways as the place of occurrence of the external cause Y92.480 Sidewalk as the place of occurrence of the external cause Y92.481 Parking lot as the place of occurrence of the external cause Y92.482 Bike path as the place of occurrence of the external cause Y92.488 Other paved roadways as the place of occurrence of the external causeICD-10-CM Coding Exercises: Place of Occurrence

ICD-10-CM External Cause of Injuries Index Activity (involving) (of victim at time of event ) - wake boarding Y93.17 - walking an animal Y93.K1 - walking (on level or elevated terrain) Y93.01 - - an animal Y93.K1 - wall climbing Y93.31 ICD-10-CM Tabular Y93.0 Activities involving walking and running Excludes1: activity, walking an animal (Y93.K1) activity, walking or running on a treadmill (Y93.A1 ) Y93.01 Activity , walking, marching and hiking Activity, walking, marching and hiking on level or elevated terrain Excludes1: activity , mountain climbing (Y93.31 ) Y93.02 Activity , running ICD-10-CM Coding Exercises: Activity Codes

ICD-10-CM External Cause of Injuries Index Status of external cause - leisure activity Y99.8 - military activity Y99.1 - off-duty activity of military personnel Y99.8 ICD-10-CM Tabular Y99 External cause status Note : A single code from category Y99 should be used in conjunction with the external cause code(s) assigned to a record to indicate the status of the person at the time the event occurred .Y99.8 Other external cause status Activity NEC Activity of child or other family member assisting in compensated work of other family member Hobby not done for income Leisure activity Off-duty activity of military personnel Recreation or sport not for income or while a student Student activity Excludes1: civilian activity done for income or compensation (Y99.0) military activity (Y99.1)ICD-10-CM Coding Exercises: External Cause Status

A woman was taking a walk along a rural road for exercise where she was struck from behind by a car. The patient suffered an open fracture of the right hip and a closed fracture of the ulna, left arm. The patient had an open reduction with internal fixation of the right hip. The left arm fracture was reduced and fitted with a cast. The patient was discharged in good condition. (Code the External Causes of Injuries codes only) V03.10xA Pedestrian on foot injured in collision with car, pick-up truck or van in traffic accident, initial encounter Y92.488 Other paved roadways as the place of occurrence of the external cause Y93.01 Activity, walking, marching and hiking Y99.8 Other external cause status ICD-10-CM Coding Exercises

ICD-10-PCS

Benefits of ICD-10-PCS Completeness Unique codes for every procedure Expandability Easy to incorporate new technology Multi-axial codes Allows for more specificity in data retrieval by each component – examples All endoscopies or biopsies Certain approaches Open Laparoscopic Everything done to one body system

Benefits of ICD-10-PCS Standardized terminology ICD-10-PCS should not include multiple meanings for the same term Each term must be assigned a specific meaning There are no eponyms or common procedure terms Diagnostic information is not included in the procedure description Not Otherwise Specified (NOS) options are restricted Limited use of Not Elsewhere Classified (NEC) option Level of specificity All procedures currently performed can be specified in ICD-10-PCS.

ICD-10-PCS Challenges Terminology Definitions ICD-10-PCS Official Guidelines for Coding and Reporting 2014 A11 Many of the terms used to construct PCS codes are defined within the system. It is the coder’s responsibility to determine what the documentation in the medical record equates to in the PCS definitions. The physician is not expected to use the terms used in PCS code descriptions, nor is the coder required to query the physician when the correlation between the documentation and the defined PCS terms is clear. Example : When the physician documents “partial resection” the coder can independently correlate “partial resection” to the root operation Excision without querying the physician for clarification.

ICD-10-PCS ICD-10-PCS Structure-Format Medical and Surgical

Structural Differences between ICD-9-CM and ICD-10-PCS Procedures

ICD-10-PCS Structure-Format: Medical and Surgical Every unique procedure code “tells a story” 1 2 3 4 5 6 7 Section Body System Root Operation Body Part Approach Device Qualifier

ICD-10-PCS Table driven There is an index which leads you to the first 3 or 4 characters of the code Once you have the code basis you go to the table for the appropriate section to complete the code

ICD-10-PCS Tables (Medical and Surgical Section Example) 4 5 6 7 Body Part Approach Device Qualifier Row Column Column Column Column ICD-10-PCS codes are found by f inding the first 3 to 7 characters in the Index, then referring to a table in the Tabular. The first three characters appear at the top of the table. Choices for the next four characters are made from the table.

The first character always refers to the Section Within each section characters 2-7 have a standardized meaning, OR, restated… Different sections may have different meanings for characters 2-7, but they will be consistent within their section There are 16 sections. Character 1: Section 1 Section

Character 1: Section 0 Medical and Surgical 1 Obstetrics 2 Placement 3 Administration 4 Measurement and Monitoring 5 Extracorporeal Assistance and Performance 6 Extracorporeal Therapies 7 Osteopathic 8 Other Procedures 9 Chiropractic B Imaging C Nuclear Medicine D Radiation Therapy F Physical Rehabilitation and Diagnostic Audiology G Mental Health H Substance Abuse Treatment

The second character indicates the general body system There are 31 body systems Some “traditional” body systems have been assigned to multiple categories Examples Upper bones Lower bones Upper arteries Lower arteries Character 2: Body System 2 Body System

Character 2: Body System 0 Central Nervous System 1 Peripheral Nervous System 2 Heart and Great Vessels 3 Upper Arteries 4 Lower Arteries 5 Upper Veins 6 Lower Veins 7 Lymphatic and Hemic System 8 Eye 9 Ear, Nose, Sinus B Respiratory System C Mouth and Throat D Gastrointestinal System F Hepatobiliary System and Pancreas G Endocrine System H Skin and Breast J Subcutaneous Tissue and Fascia

Character 2: Body System, cont. K Muscles L Tendons M Bursae and Ligaments N Head and Facial Bones P Upper Bones Q Lower Bones R Upper Joints S Lower Joints T Urinary System U Female Reproductive System V Male Reproductive System W Anatomical Regions, General X Anatomical Regions, Upper Extremities Y Anatomical Regions, Lower Extremities

The third character indicates the root operation Specifies the objective of the procedure There are 31 Root Operations in the Medical Surgical Section Each is specifically defined Mastering the definitions and understanding their specificity is the greatest challenge of I-10 procedural coding Character 3: Root Operations 3 Root Operation

Root Operation Principles A root operation is coded according to the objective of the procedure actually performed Composite terms are not root operationsCombination procedures are coded separately The complete or partial redo of a procedure is coded to the root operation performed rather than “Revision” Character 3: Root Operations

Alteration Bypass Change Control Creation Destruction Detachment Dilation Division Drainage Character 3: Root Operations, cont. Excision Extirpation Extraction Fragmentation Fusion Insertion Inspection Map Occlusion Reattachment Release Removal Repair Replacement Reposition Resection Restriction Revision SupplementTransferTransplantation

Character 3: Root Operations Alteration Modifying the anatomic structure of a body part without affecting the function of the body part Bypass Altering the route of passage of the contents of a tubular body part Change Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane Control Stopping, or attempting to stop, postprocedural bleeding Creation Making a new genital structure that does not take over the function of a body part Destruction Physical eradication of all or a portion of a body part by the direct use of energy, force or a destructive agent Detachment Cutting off all or part of the upper or lower extremities Dilation Expanding an orifice or the lumen of a tubular body part

Character 3: Root Operations, cont. Division Cutting into a body part without draining fluids and/or gases from the body part in order to separate or transect a body part Drainage Taking or letting out fluids and/or gases from a body part Excision Cutting out or off, without replacement, a portion of a body part Extirpation Taking or cutting out solid matter from a body part Extraction Pulling or stripping out or off all or a portion of a body part by the use of force Fragmentation Breaking solid matter in a body part into pieces Fusion Joining together portions of an articular body part rendering the articular body part immobile Insertion Putting in a non-biological appliance that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part

Character 3: Root Operations, cont. Inspection Visually and/or manually exploring a body part Map Locating the route of passage of electrical impulses and/or locating functional areas in a body part Occlusion Completely closing an orifice or the lumen of a tubular body part Reattachment Putting back in or on all or a portion of a separated body part to its normal location or other suitable location Release Freeing a body part from an abnormal physical constraint by cutting or by use of force Removal Taking out or off a device from a body part Repair Restoring, to the extent possible, a body part to its normal anatomic structure and function Replacement Putting in or on biological or synthetic material that physically takes the place of all or a portion of a body part

Character 3: Root Operations, cont. Reposition Moving to its normal location or other suitable location all or a portion of a body part Resection Cutting out or off, without replacement, all of a body part Restriction Partially closing an orifice or the lumen of a tubular body part Revision Correcting, to the extent possible, a malfunctioning or displaced device Supplement Putting in or on biological or synthetic material that physically reinforces and/or augments the function of a body part Transfer Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part Transplantation Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part

Character 4: Body Part The body part indicates the specific part of the body system on which the procedure was performed (e.g., if the Body System, character 2, was Gastrointestinal then the Body Part, character 4, could be duodenum). Tubular body parts are defined in ICD-10-PCS as those hollow body parts that provide a route of passage for solids, liquids, or gases. They include the cardiovascular system, and body parts such as those contained in the gastrointestinal tract, genitourinary tract, biliary tract, and respiratory tract. 4 Body Part

Character 5: Approach The fifth character is the technique used to reach the site of the procedure Open Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure Percutaneous Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach the site of the procedure Percutaneous Endoscopic Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and/or any other body layers necessary to reach and visualize the site of the procedure Via Natural or Artificial Opening Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure 5 Approach

Character 5: Approach, cont Via Natural or Artificial Opening Endoscopic Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure Via Natural or Artificial Opening Endoscopic with Percutaneous Endoscopic Assistance Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure, and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure External Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane

Character 6: Device The device character is only used to specify devices that remain after the procedure is completed. Does not include materials incidental to a procedure, such as sutures There are four basic groups: Grafts and Prostheses Implants Simple or Mechanicals Appliances Electronic Appliances When no device is used, character “Z”, representing “none,” is used as the sixth character 6 Device

Examples of devices: Biological or synthetic material that takes the place of all or a portion of a body part ( e.g, skin graft, joint prosthesis). Biological or synthetic material that assists or prevents a physiological function (e.g., IUD). Therapeutic material that is not absorbed by, eliminated by, or incorporated into a body part (e.g., radioactive implant). Mechanical or electronic appliances used to assist, monitor, take the place of or prevent a physiological function (e.g., cardiac pacemaker, orthopedic pin). Character 6: Device, cont.

Character 7: Qualifier The seventh character, the qualifier, contains unique values for individual procedures as needed. Example: Used to identify the destination site in a bypass. When there is no qualifier, character “Z”, representing “none,” is used as the seventh character 7 Qualifier

Code Comparison

Code Comparison - Procedure Procedure – Transverse colon resection, open ICD-9-CM 45.74 Open/other resection of transverse colon ICD-10-PCS 0DTL0ZZ

Breakdown of the ICD-10-PCS Code Character 1 Section Character 2 Body System Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 Qualifier Medical and Surgical Gastro-intestinal System Resection Trans-verse Colon Open No Device No Qualifier 0 D T L 0 Z Z Transverse colon resection, open

Procedure – Gallbladder resection, laparoscopic ICD-9-CM 51.23 ICD-10-PCS 0FT44ZZ Code Comparison - Procedure

Breakdown of the ICD-10-PCS Code Character 1 Section Character 2 Body System Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 Qualifier Medical and Surgical Hepato-billiary System and Pancreas Resection Gall-bladder Percu-taneous Endo- scopic No Device No Qualifier 0 F T 4 4 Z Z Gallbladder resection, laparoscopic

Coding Exercises ICD-10-PCS

Take Out Some or All of a Body Part – Exercise 1 Procedure: Rectal polyp fulguration via sigmoidoscope Fulguration see Destruction Destruction Rectum 0D5P Retina Left 085F3ZZ Right 085E3ZZ

Take Out Some or All of a Body Part – Exercise 1

Take Out Some or All of a Body Part – Exercise 1 Character 1 Section Character 2 Body System Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 Qualifier Medical and Surgical Gastro- intestinal Destruction Rectum Via Natural or Artificial Opening Endoscopic No Device No Qualifier 0 D 5 P 8 Z Z Rectal polyp fulguration via sigmoidoscope

Take Out Solids, Fluids, or Gases from a Body Part – Exercise 2 Procedure: Percutaneous mechanical thrombectomy , left brachial artery Thrombectomy see Extirpation Extirpation Artery Brachial Left 03C8 Right 03C7

Take Out Solids, Fluids, or Gases from a Body Part – Exercise 2

Take Out Solids, Fluids, or Gases from a Body Part – Exercise 2 Character 1 Section Character 2 Body System Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 Qualifier Medical and Surgical Upper Arteries Extirpation Brachial artery, left Percu-taneous No Device No Qualifier 0 3 C 8 3 Z Z Percutaneous mechanical thrombectomy , left brachial artery

Involve Cutting or Separation Only - Exercise 3 Procedure: Laparotomy with lysis of large intestine adhesions Lysis see Release Release Intestine Large 0DNE Left 0DNG Right 0DNF Small 0DN8

Involve Cutting or Separation Only - Exercise 3

Involve Cutting or Separation Only - Exercise 3 Character 1 Section Character 2 Body System Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 Qualifier Medical and Surgical Gastrointestinal Release Large Intestine Open No Device No Qualifier 0 D N E 0 Z Z Laparotomy with lysis of large intestine adhesions

That Put In/Put Back or Move Some/All of a Body Part: Exercise 4 Procedure: Closed reduction of dislocation of the right shoulder joint Reduction Dislocation see Reposition Fracture see Reposition Reposition Joint Shoulder Left 0RSK Right 0RSJ

That Put In/Put Back or Move Some/All of a Body Part: Exercise 4

That Put In/Put Back or Move Some/All of a Body Part: Exercise 4 Character 1 Section Character 2 Body System Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 Qualifier Medical and Surgical Upper joints Reposition Shoulder, joint right External No Device No Qualifier 0 R S J X Z Z Closed reduction of dislocation of the right shoulder joint

Alter the Diameter/Route of a Tubular Body Part – Exercise 5 Procedure: Laparoscopic bilateral fallopian tube ligation. Ligation see Occlusion Occlusion Fallopian Tube Left 0UL6 Right 0UL5 Fallopian Tubes, Bilateral 0UL7

Alter the Diameter/Route of a Tubular Body Part – Exercise 5

Alter the Diameter/Route of a Tubular Body Part – Exercise 5 Character 1 Section Character 2 Body System Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 Qualifier Medical and Surgical Female Reproductive Occlusion Fallopian Tubes, Bilateral Percu-taneous Endos-copic No Device No Qualifier 0 U L 7 4 Z Z Laparoscopic bilateral fallopian tube ligation

Always Involve a Device – Exercise 6 Procedure: Laparotomy with left ventral hernia repair with Merlex mesh Herniorrhaphy see Repair, Anatomical Regions, General 0WQ see Repair, Anatomical Regions, Lower Extremities 0YQ with synthetic substitute see Supplement, Anatomical Regions, General 0WU see Supplement, Anatomical Regions, Lower Extremities 0YU Supplement Abdominal Wall 0WUF

Always Involve a Device – Exercise 6

Always Involve a Device – Exercise 6 Character 1 Section Character 2 Body System Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 Qualifier Medical and Surgical General Supplement Abdominal Wall Open Synthetic Substitute No Qualifier 0 W U F 0 J Z Laparotomy with left ventral hernia repair with Merlex mesh

Coding Exercise ICD-10-CM and ICD-10-PCS

Patient is brought to the hospital by ambulance after being caught in an avalanche while skiing at a mountain resort while on vacation. Patient presented with a displaced fracture dislocation of the left humerus , surgical neck. An open reduction with internal fixation was performed using pins and screws. Coding Exercise: ICD-10-CM and ICD-10-PCS

ICD-10-CM Index Dislocation (articular) - with fracture — see Fracture Fracture , traumatic (abduction) (adduction) (separation) ( see also Fracture , pathological) T14.8 - humerus S42.30-- - surgical neck —see Fracture, humerus, upper end, surgical neck- - upper end S42.20-- - - surgical neck (displaced) S42.21- ICD-10-CM Tabular The appropriate 7th character is to be added to all codes from category S42 A - initial encounter for closed fracture B - initial encounter for open fracture D - subsequent encounter for fracture with routine healing G - subsequent encounter for fracture with delayed healing K - subsequent encounter for fracture with nonunion P - subsequent encounter for fracture with malunion S - sequela S42.2 Fracture of upper end of humerusS42.21 Unspecified fracture of surgical neck of humerusS42.212 Unspecified displaced fracture of surgical neck of left humerusCoding Exercise: ICD-10-CM

ICD-10-CM External Cause of Injuries Index Avalanche — see Landslide Landslide (falling on transport vehicle) X36.1 - caused by collapse of man-made structure X36.0 ICD-10-CM Tabular X36 Avalanche , landslide and other earth movements Includes : victim of mudslide of cataclysmic natureExcludes1 : earthquake (X34) Excludes2 : transport accident involving collision with avalanche or landslide not in motion (V01-V99) The appropriate 7th character is to be added to each code from category X36 A - initial encounter D - subsequent encounter S - sequela X36.0 Collapse of dam or man-made structure causing earth movementX36.1 Avalanche, landslide, or mudslideCoding Exercise: ICD-10-CM: External Cause of Morbidity

ICD-10-CM External Cause of Injuries Index Place of occurrence - motorway (interstate) Y92.411 - mountain Y92.828 - movie-house Y92.26 - museum Y92.251 - music-hall Y92.252 ICD-10-CM Tabular Y92.8 Other places as the place of occurrence of the external cause Y92.83 Recreation area as the place of occurrence of the external cause Y92.838 Other recreation area as the place of occurrence of the external cause Coding Exercise: ICD-10-CM: Place of Occurrence

ICD-10-CM External Cause of Injuries Index Activity (involving) (of victim at time of event ) - skiing (alpine) (downhill) Y93.23 - - cross country Y93.24 - - nordic Y93.24 - - water Y93.17 ICD-10-CM Tabular Y93.2 Activities involving ice and snow Excludes1 : activity, shoveling ice and snow (Y93.H1)Y93.21 Activity , ice skating Activity , figure skating (singles) (pairs) Activity , ice dancing activity , ice hockey (Y93.22) Y93.22 Activity , ice hockey Y93.23 Activity , snow (alpine) (downhill) skiing, snow boarding, sledding, tobogganing and snow tubing Excludes1: activity, cross country skiing (Y93.24)Coding Exercise: ICD-10-CM: Activity Codes

ICD-10-CM External Cause of Injuries Index Status of external cause - leisure activity Y99.8 - military activity Y99.1 - off-duty activity of military personnel Y99.8 ICD-10-CM Tabular Y99 External cause status Note : A single code from category Y99 should be used in conjunction with the external cause code(s) assigned to a record to indicate the status of the person at the time the event occurred .Y99.8 Other external cause status Activity NEC Activity of child or other family member assisting in compensated work of other family member Hobby not done for income Leisure activity Off-duty activity of military personnel Recreation or sport not for income or while a student Student activity Excludes1: civilian activity done for income or compensation (Y99.0) military activity (Y99.1)Coding Exercise: ICD-10-CM: External Cause Status

Procedure: An open reduction with internal fixation was performed using pins and screws. Reposition Humeral Head Left 0PSD Right 0PSC Humeral Shaft Left 0PSG Right 0PSF Coding Exercise: ICD-10-PCS

Coding Exercise: ICD-10-PCS

Always Involve a Device – Exercise 6 Character 1 Section Character 2 Body System Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 Qualifier Medical and Surgical Upper Bones Reposition Humeral Head, Left Open Internal Fixation Device No Qualifier 0 P S D 0 4 Z An open reduction with internal fixation was performed using pins and screws

Patient is brought to the hospital by ambulance after being caught in an avalanche while skiing at a mountain resort while on vacation. Patient presented with a displaced fracture dislocation of the left humerus , surgical neck. An open reduction with internal fixation was performed using pins and screws. S42.212A Unspecified displaced fracture of surgical neck of left humerus , initial encounter X36.1 Avalanche, landslide, or mudslide Y92.838 Other recreation area as the place of occurrence of the external cause Y93.23 Activity, snow (alpine) (downhill) skiing, snow boarding, sledding, tobogganing and snow tubing Y99.8 Other external cause status0PSD04Z An open reduction with internal fixation was performed using pins and screws Coding Exercise: ICD-10-CM and ICD-10-PCS

How do I get started?

How do I get started? Get out your anatomy and physiology references and renew/expand your knowledge of the topics Greater specificity of the code sets requires more detailed knowledge of anatomy and physiology to make correct code selections 146

How do I get started? Keep current on ICD-10 topics Subscribe to AHIMA ICD-TEN http://www.ahima.org/images/newsletters/ICDTen/subscribe.html Subscribe to ICD10 WATCH http://www.icd10watch.com/ Find other on-line newsletters and websites 147

How do I get started? Begin reviewing the ICD-10 guidelines ICD-10-CM http://www.cdc.gov/nchs/data/icd9/icd10cm_guidelines_2014.pdf ICD-10-PCS http:// www.cms.gov/Medicare/Coding/ICD10/Downloads/PCS-2014-guidelines.pdf Access the code sets ICD-10-CM and ICD-10-PCS http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ icd10 148

How do I get started? Visit the websites of the cooperating parties to see what is available on ICD-10 American Hospital Association www.ahacentraloffice.org American Health Information Management Association www.ahima.org National Center for Health Statistics www.cdc.gov/nchs/about/otheract/icd9/abticd10.htm Centers for Medicare & Medicaid Services www.cms.hhs.gov/icd10 149

Questions??? 150

Katherine “Kitty” Kremer, BA, RHIT | Director Coding Education AHIMA Approved ICD-10-CM/PCS Trainer, AHIMA ICD-10 Ambassador  Anthelio Healthcare Solutions Inc. Office: (248) 536-4374 | Mobile: (313) 215-3267 Fax: (248) 536-4387 | Email: kitty.kremer@antheliohealth.com Deidre Brown, BS, CCS |  Anthelio ICD-10-CM/PCS Training Specialist AHIMA Approved ICD-10-CM/PCS Trainer Anthelio Healthcare Solutions Inc. Office: (248) 536-4371Fax: (248) 536-4387 | Email: deidre.brown3@antheliohealth.comHow can we help?